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Academic Coaching Service Request

Contact Information
Please share your demograhic information to assist the Academic Coaching Program with matching you with your future Academic Coach. All information is kept strickly confidential and will not be shared with anyone outside of the program. To contact the program, email Michael Stokes at stokesm@smccd.edu or call 650-738-4144.
1.
What is your name? ✱
Firstname
Lastname
2.
What is your G number? ✱
3.
Please provide your contact information. ✱
Email:
Cell phone:
Home phone:
4.
Of the various ways you listed to contact you, which is your preferred method of contact?
5.
Do you have a physical or learning difference or difficulty?
6.
If you answered yes to having a learning difference or difficulty, please summarize the nature of it below.
7.
Please list all languages you speak fluently other than English.